AAFP, Others Protest VA's Attempt to Expand APRNs' Scope of Practice

Proposal Would Eliminate Physician-led, Team-based Care

The AAFP joined the AMA and a host of other national physician organizations -- as well as 43 state medical societies and associations -- in asking the Department of Veterans Affairs (VA) to hit the pause button before finalizing the draft version of a handbook that establishes guidelines for nursing care within the Veterans Health Administration (VHA) system.

"We strongly urge that revisions be made to the draft VHA Nursing Handbook to ensure that current VHA policies in support of physician-led health care teams and state-based licensure and regulation remain unchanged," say the 66 organizations in an Oct. 28 letter to Robert Petzel, M.D., VA undersecretary for health.

The letter expresses "strong concerns" with directives in the handbook that would mandate that all advanced practice registered nurses (APRNs) within the VHA be designated as independent health care providers regardless of individual state regulations.

The organizations argue that the nursing handbook, as drafted, "effectively eliminates physician-led, team-based care within the VHA system."

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The AAFP is urging the Department of Veterans Affairs (VA) to revise a draft copy of its Veterans Health Administration (VHA) Affairs nursing handbook that would require all advanced practice registered nurses (APRNs) in the VHA system to attain independent practice status.

The AAFP and other medical organizations joined forces in a letter to the VA that points out the cost and quality benefits of team-based health care.

The organizations call APRNs indispensable members of health care teams that should be led by highly trained physicians.

According to the draft version, APRNs would be required to attain independent practice or be prohibited from practicing with the VHA. Furthermore, local facilities would be prohibited from providing physician-led, team-based care.

In their letter, the physician organizations acknowledge the nation's shortage of both physicians and nurses amid a growing demand for primary care. But they point out that emerging models of care, including accountable care organizations and patient-centered medical homes, use team-based care to improve patient care and lower costs.

The letter stresses that organizations such as Geisinger Health System, the Mayo Clinic and Kaiser Permanente successfully use physician-led teams to achieve positive results. "The undersigned organizations look to these physician-led systems as evidence that team-based models of care -- not independent models -- are the future of the health care," says the letter.

Furthermore, every team -- be it in the business sector or sports-related -- needs good leaders. Physicians, with their high level of training and preparation, are best positioned to serve as the leaders of health care teams.

"APRNs are indispensable, but they cannot take the place of a fully trained physician," says the letter. Physicians provide complex diagnoses and develop treatment plans that address multiple organ systems. They are trained to both order and interpret tests related to a patient's health condition.

On the other hand, APRNs deal with basic preventive care and treatment of acute illnesses and previously diagnosed chronic conditions.

"APRNs and physicians have skills, knowledge and abilities that are not equivalent, but instead are complementary," says the letter. "Taking a team-based approach to care can address much of the primary care demand within the VHA," it concludes.

As for the AAFP, the recent joint letter represents the Academy's ongoing advocacy with the VA on the issue of expanding the role of APRNs within the VHA.

In June, (then) AAFP Board Chair Glen Stream, M.D., M.B.I., of Spokane, Wash., wrote to the VA questioning the federal government's intention to expand the role of nurse practitioners within the VHA system without going through the normal rule-making process.

At that time, Stream wrote, "The AAFP remains concerned that the public is not being given pertinent details (about this expansion of scope) since the VA apparently is not issuing a proposed rule."

He continued, "The AAFP considers this a major policy change that, (though) perhaps well-intended, may have unforeseen consequences, and thus we believe the issue is worthy of a normal public rulemaking process."

As of the publication date of this article, the issue surrounding the VA's expansion of APRN licensure had not yet been resolved; the AAFP plans to continue discussions with the VA to work toward a successful resolution.